Travel Form

If you are travelling abroad and require advice and/or vaccinations please click here to download the travel vaccination and enquiry form which you should complete and hand in to reception. Once the form has been completed in full and returned to us you can make an appointment with the nurse. Alternatively it can be completed online below. The form should be submitted and the appointment arranged 6-8 weeks before you travel to ensure that any course of vaccinations required can be appropriately completed and be considered effective.

Please click here for more details about current charges to patients for travel vaccinations or certificates. All payments are to be made by cash or cheque only.

Please note that if completing this form you must read the additional information and guidance supplied HERE and also make an appointment with the nurse for your travel consultation and any vaccinations if you wish to proceed. Travel vaccination charges where these apply will need to be paid on the first visit and for any courses these are non-refundable.

Please note there is currently a national shortage of Hepatitis A&B vaccine so the practice cannot provide these at the present time. The nurse will advise you if these vaccines are available alternatively you can consult with a local private travel clinic.

1Travel Form

Travel risk assessment and enquiry form – to be completed by the traveller 6-8 weeks prior to travel and prior to an appointment being made with the nurse.

Full Name:

Address:

Date of Birth:

Gender:

Home Telephone Number:

Mobile Telephone Number:

Date of Departure:

Total Duration of Trip

County 1 to be visited

Exact location of region 1

City or rural area 1

Length of stay 1

County 2 to be visited

Exact location of region 2

City or rural area 2

Length of stay 2

County 3 to be visited

Exact location of region 3

City or rural area 3

Length of stay 3

County 4 to be visited

Exact location of region 4

City or rural area 4

Length of stay 4

Have you taken travel insurance for this trip?

Do you plan to travel abroad again in the future?

Type of travel and purpose of trip (please tick all that apply):

Holiday

Business Trip

Expatriate

Volunteer Work

Healthcare Worker

Staying in Hotel

Cruise Ship

Safari

Pilgrimage

Medical Tourism

Backpacking

Camping/Hostel

Adventure

Diving

Visiting Family/Friends

Any additional information about your trip?

2Medical History

Please provide details about your personal medical history below:

Are you fit and well today?

If not, please provide details:

Do you suffer from any allergies including food, latex or medication?

If yes, please provide details:

Have you had a severe reaction to a vaccination before?

If yes, please provide details:

Do you have a tendency to faint after a vaccination?

If yes, please provide details:

Have you had any surgical operations in the past including your spleen or thymus gland being removed?

If yes, please provide details:

Had you undergone recent chemotherapy, radiotherapy or organ transplantation?

If yes, please provide details:

Do you suffer from anaemia?

If yes, please provide details:

Do you suffer from any bleeding or clotting disorders (including history of DVT)?

If yes, please provide details:

Do you suffer from heart disease (including high blood pressure or angina)?

If yes, please provide details:

Are you a diabetic?

If yes, please provide details:

Do you have a disability?

If yes, please provide details:

Do you suffer from epilepsy or seizures?

If yes, please provide details:

Do you suffer from any gastrointestinal (stomach) complaints?

If yes, please provide details:

Do you suffer from any liver and/or kidney problems?

If yes, please provide details:

Do you have HIV or AIDS?

If yes, please provide details:

Do you have any condition affecting your immune system?

If yes, please provide details:

Do you suffer from any mental health issues (including anxiety or depression)?

If yes, please provide details:

Do you suffer from any neurological (nervous system) illness?

If yes, please provide details:

Do you suffer from any respiratory (lung) disease?

If yes, please provide details:

Do you suffer from any rheumatologic (joint) conditions?

If yes, please provide details:

Do you have any spleen problems?

If yes, please provide details:

Do you have any other conditions?

If yes, please provide details:

3Women Only

Are you pregnant?

If yes, please provide details:

Are you breast feeding?

If yes, please provide details:

Are you planning a pregnancy whilst away?

If yes, please provide details:

Are you currently taking any medication (including prescribed, purchased or a contraceptive pill)?

If yes, please give details of all:

4Vaccinations

Typhoid:

Hepatitis A:

Pneumococcal:

Cholera:

Hepatitis B:

Meningitis:

Rabies:

Tetanus/Polio/Diptheria:

MMR:

Influenza:

Japanese Encephalitis:

Tick Borne Encephalitis:

Yellow Fever:

BCG:

Malaria Tablets:

Other:

Any other relevant information:

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